Borderline personality disorder

Abstract

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in 1.7% of the general population but in 15–28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

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Figure 1: Milestones in BPD diagnosis, underlying mechanisms and treatment.
Figure 2: Symptom phenotypes of BPD.
Figure 3: Alterations of brain circuits in BPD.
Figure 4: Rates of symptomatic remission of BPD.

References

  1. 1

    Black, D. W. et al. Attitudes toward borderline personality disorder: a survey of 706 mental health clinicians. CNS Spectr. 16, 67–74 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  2. 2

    Linehan, M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. (Guilford Press, 1993).

    Google Scholar 

  3. 3

    Bateman, A. & Fonagy, P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am. J. Psychiatry 156, 1563–1569 (1999).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  4. 4

    Clarkin, J. F., Levy, K. N., Lenzenweger, M. F. & Kernberg, O. F. Evaluating three treatments for borderline personality disorder: a multiwave study. Am. J. Psychiatry 164, 922–928 (2007). This study compares a psychoanalytically based therapy (TFP) to a behavioural therapy (DBT) and a non-intensive supportive generalist therapy, finding that they had comparable outcomes and thereby legitimizing both the psychoanalytic and supportive models.

    PubMed  Article  Google Scholar 

  5. 5

    Zanarini, M. C., Frankenburg, F. R., Reich, D. B. & Fitzmaurice, G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: a 16-year prospective follow-up study. Am. J. Psychiatry 169, 476–483 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6

    Gunderson, J. G. et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Arch. Gen. Psychiatry 68, 827–837 (2011). This paper highlights how patients with BPD frequently can have enduring symptom remissions while still having severe functional impairments.

    PubMed  PubMed Central  Article  Google Scholar 

  7. 7

    Torgersen, S. et al. A twin study of personality disorders. Compr. Psychiatry 41, 416–425 (2000). This article presents the first methodologically robust twin study of BPD; it established the heritability of BPD at a time when the aetiology of this disorder was considered to be exclusively environmental.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  8. 8

    Torgersen, S., Kringlen, E. & Cramer, V. The prevalence of personality disorders in a community sample. Arch. Gen. Psychiatry 58, 590–596 (2001). The article presents the prevalence and associations of sociodemographic variables to personality disorders, applying multivariate analyses in a large representative sample from the common population.

    CAS  PubMed  Article  Google Scholar 

  9. 9

    Johnson, J. G., Cohen, P., Kasen, S., Skodol, A. E. & Oldham, J. M. Cumulative prevalence of personality disorders between adolescence and adulthood. Acta Psychiatr. Scand. 118, 410–413 (2008). The article presents a longitudinal study of personality disorders at four ages over almost 20 years.

    PubMed  Article  Google Scholar 

  10. 10

    Torgersen, S. in American Psychiatric Publishing Textbook of Personality Disorders 2nd edn (ed. Oldham, J. M., Skodol, A. E., Bender, D. S. ) 109–129 (American Psychiatric Publishing, Washington, DC, 2014).

    Google Scholar 

  11. 11

    Grant, B. F. et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J. Clin. Psychiatry 69, 533–545 (2008).

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12

    Kaess, M., Brunner, R. & Chanen, A. Borderline personality disorder in adolescence. Pediatrics 134, 782–793 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  13. 13

    Tomko, R. L., Trull, T. J., Wood, P. K. & Sher, K. J. Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning. J. Pers. Disord. 28, 734–750 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  14. 14

    Bender, D. S. et al. Treatment utilization by patients with personality disorders. Am. J. Psychiatry 158, 295–302 (2001).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  15. 15

    Zanarini, M. C., Frankenburg, F. R., Hennen, J. & Silk, K. R. Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. J. Clin. Psychiatry 65, 28–36 (2004).

    PubMed  Article  PubMed Central  Google Scholar 

  16. 16

    Chanen, A. M. et al. Screening for borderline personality disorder in outpatient youth. J. Pers. Disord. 22, 353–364 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17

    Zimmerman, M., Chelminski, I. & Young, D. The frequency of personality disorders in psychiatric patients. Psychiatr. Clin. North Am. 31, 405–420 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  18. 18

    Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L. & Webb, S. P. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Compr. Psychiatry 49, 380–386 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  19. 19

    Gross, R. et al. Borderline personality disorder in primary care. Arch. Intern. Med. 162, 53 (2002).

    PubMed  Article  PubMed Central  Google Scholar 

  20. 20

    Chaput, Y. J. A. & Lebel, M.-J. Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services. Psychiatr. Serv. 58, 335–341 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  21. 21

    Torgersen, S. in The Oxford Handbook of Personality Disorders (ed. Widiger, T. A. ) 186–205 (Oxford Univ. Press, New York, 2012).

    Google Scholar 

  22. 22

    Cramer, V., Torgersen, S. & Kringlen, E. Personality disorders and quality of life. A population study. Compr. Psychiatry 47, 178–184 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  23. 23

    Cramer, V., Torgersen, S. & Kringlen, E. Socio-demographic conditions, subjective somatic health, Axis I disorders and personality disorders in the common population: the relationship to quality of life. J. Pers. Disord. 21, 552–567 (2007). The article presents a study of the influence of personality disorders on different aspects of quality of life, compared to, and controlled for, different sociodemographic variables and Axis I disorders.

    PubMed  Article  PubMed Central  Google Scholar 

  24. 24

    Ullrich, S. & Coid, J. The age distribution of self-reported personality disorder traits in a household population. J. Pers. Disord. 23, 187–200 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  25. 25

    Cattane, N., Rossi, R., Lanfredi, M. & Cattaneo, A. Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms. BMC Psychiatry 17, 221 (2017).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  26. 26

    Feldker, K. et al. Transdiagnostic brain responses to disorder-related threat across four psychiatric disorders. Psychol. Med. 47, 730–743 (2017).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  27. 27

    Dannlowski, U. et al. Limbic scars: long-term consequences of childhood maltreatment revealed by functional and structural magnetic resonance imaging. Biol. Psychiatry 71, 286–293 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  28. 28

    Distel, M. A. et al. Life events and borderline personality features: the influence of gene–environment interaction and gene–environment correlation. Psychol. Med. 41, 849–860 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  29. 29

    Zanarini, M. C. et al. Reported pathological childhood experiences associated with the development of borderline personality disorder. Am. J. Psychiatry 154, 1101–1106 (1997).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  30. 30

    Afifi, T. O. et al. Childhood adversity and personality disorders: results from a nationally representative population-based study. J. Psychiatr. Res. 45, 814–822 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  31. 31

    Hengartner, M. P., Ajdacic-Gross, V., Rodgers, S., Müller, M. & Rössler, W. Childhood adversity in association with personality disorder dimensions: new findings in an old debate. Eur. Psychiatry 28, 476–482 (2013).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  32. 32

    Johnson, J. G., Cohen, P., Brown, J., Smailes, E. M. & Bernstein, D. P. Childhood maltreatment increases risk for personality disorders during early adulthood. Arch. Gen. Psychiatry 56, 600 (1999).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  33. 33

    Johnson, J. G., Cohen, P., Chen, H., Kasen, S. & Brook, J. S. Parenting behaviors associated with risk for offspring personality disorder during adulthood. Arch. Gen. Psychiatry 63, 579 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  34. 34

    Crawford, T. N., Cohen, P. R., Chen, H., Anglin, D. M. & Ehrensaft, M. Early maternal separation and the trajectory of borderline personality disorder symptoms. Dev. Psychopathol. 21, 1013 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  35. 35

    Rogosch, F. A. & Cicchetti, D. Child maltreatment and emergent personality organization: perspectives from the five-factor model. J. Abnorm. Child Psychol. 32, 123–145 (2004).

    PubMed  Article  PubMed Central  Google Scholar 

  36. 36

    Fonagy, P. & Bateman, A. The development of borderline personality disorder — a mentalizing model. J. Pers. Disord. 22, 4–21 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  37. 37

    Stepp, S. D. & Lazarus, S. A. Identifying a borderline personality disorder prodrome: implications for community screening. Personal. Ment. Health 11, 195–205 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  38. 38

    Helgeland, M. I., Kjelsberg, E. & Torgersen, S. Continuities between emotional and disruptive behavior disorders in adolescence and personality disorders in adulthood. Am. J. Psychiatry 162, 1941–1947 (2005).

    PubMed  Article  PubMed Central  Google Scholar 

  39. 39

    Stepp, S. D., Burke, J. D., Hipwell, A. E. & Loeber, R. Trajectories of attention deficit hyperactivity disorder and oppositional defiant disorder symptoms as precursors of borderline personality disorder symptoms in adolescent girls. J. Abnorm. Child Psychol. 40, 7–20 (2011).

    Article  Google Scholar 

  40. 40

    Chanen, A. M. & Kaess, M. Developmental pathways to borderline personality disorder. Curr. Psychiatry Rep. 14, 45–53 (2011).

    Article  Google Scholar 

  41. 41

    Gunderson, J. G. Family study of borderline personality disorder and its sectors of psychopathology. Arch. Gen. Psychiatry 68, 753 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  42. 42

    Torgersen, S. et al. The heritability of cluster B personality disorders assessed both by personal interview and questionnaire. J. Pers. Disord. 26, 848–866 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43

    Reichborn-Kjennerud, T. et al. A longitudinal twin study of borderline and antisocial personality disorder traits in early to middle adulthood. Psychol. Med. 45, 3121–3131 (2015).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  44. 44

    Grilo, C. M. et al. Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study. Can. J. Psychiatry 52, 357–362 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  45. 45

    Torgersen, S. et al. Dimensional representations of DSM-IV cluster B personality disorders in a population-based sample of Norwegian twins: a multivariate study. Psychol. Med. 38, 1617 (2008).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  46. 46

    Kendler, K. S. et al. The structure of genetic and environmental risk factors for DSM-IV personality disorders. Arch. Gen. Psychiatry 65, 1438 (2008).

    PubMed  PubMed Central  Article  Google Scholar 

  47. 47

    Bornovalova, M. A., Hicks, B. M., Iacono, W. G. & McGue, M. Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study. Dev. Psychopathol. 21, 1335 (2009).

    PubMed  PubMed Central  Article  Google Scholar 

  48. 48

    Amad, A., Ramoz, N., Thomas, P., Jardri, R. & Gorwood, P. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. Neurosci. Biobehav. Rev. 40, 6–19 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  49. 49

    Witt, S. H. et al. Genome-wide association study of borderline personality disorder reveals genetic overlap with bipolar disorder, major depression and schizophrenia. Transl Psychiatry 7, e1155 (2017).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  50. 50

    Prados, J. et al. Borderline personality disorder and childhood maltreatment: a genome-wide methylation analysis. Genes Brain Behav. 14, 177–188 (2015).

    CAS  Google Scholar 

  51. 51

    Perroud, N. et al. Response to psychotherapy in borderline personality disorder and methylation status of the BDNF gene. Transl Psychiatry 3, e207–e207 (2013).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  52. 52

    Martín-Blanco, A. et al. The role of hypothalamus–pituitary–adrenal genes and childhood trauma in borderline personality disorder. Eur. Arch. Psychiatry Clin. Neurosci. 266, 307–316 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  53. 53

    de Kloet, E. R., Joëls, M. & Holsboer, F. Stress and the brain: from adaptation to disease. Nat. Rev. Neurosci. 6, 463–475 (2005).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  54. 54

    Carrion, V. G. & Wong, S. S. Can Traumatic Stress Alter the Brain? Understanding the implications of early trauma on brain development and learning. J. Adolesc. Health 51, S23–S28 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  55. 55

    Di Iorio, C. R. et al. Hypothalamic-pituitary-adrenal axis genetic variation and early stress moderates amygdala function. Psychoneuroendocrinology 80, 170–178 (2017).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  56. 56

    Veer, I. M. et al. Endogenous cortisol is associated with functional connectivity between the amygdala and medial prefrontal cortex. Psychoneuroendocrinology 37, 1039–1047 (2012).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  57. 57

    Pratt, M. et al. Mother-child adrenocortical synchrony; moderation by dyadic relational behavior. Horm. Behav. 89, 167–175 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  58. 58

    Feldman, R., Gordon, I., Schneiderman, I., Weisman, O. & Zagoory-Sharon, O. Natural variations in maternal and paternal care are associated with systematic changes in oxytocin following parent–infant contact. Psychoneuroendocrinology 35, 1133–1141 (2010).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  59. 59

    Fonagy, P., Luyten, P. & Allison, E. Epistemic petrification and the restoration of epistemic trust: a new conceptualization of borderline personality disorder and its psychosocial treatment. J. Pers. Disord. 29, 575–609 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  60. 60

    Sharp, C. et al. Theory of mind and emotion regulation difficulties in adolescents with borderline traits. J. Am. Acad. Child Adolesc. Psychiatry 50, 563–573.e1 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  61. 61

    Krause-Utz, A. et al. Amygdala and dorsal anterior cingulate connectivity during an emotional working memory task in borderline personality disorder patients with interpersonal trauma history. Front. Hum. Neurosci. 8, 848 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  62. 62

    Beeney, J. E., Hallquist, M. N., Ellison, W. D. & Levy, K. N. Self-other disturbance in borderline personality disorder: neural, self-report, and performance-based evidence. Personal. Disord. 7, 28–39 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  63. 63

    New, A. S. et al. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J. Pers. Disord. 26, 660–675 (2012).

    PubMed  Article  Google Scholar 

  64. 64

    Domes, G., Grabe, H. J., Czieschnek, D., Heinrichs, M. & Herpertz, S. C. Alexithymic Traits and Facial Emotion Recognition in Borderline Personality Disorder. Psychother. Psychosom. 80, 383–385 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  65. 65

    Meaney, R., Hasking, P. & Reupert, A. Borderline personality disorder symptoms in college students: the complex interplay between alexithymia, emotional dysregulation and rumination. PLoS ONE 11, e0157294 (2016).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  66. 66

    Mier, D. et al. Neuronal correlates of social cognition in borderline personality disorder. Soc. Cogn. Affect. Neurosci. 8, 531–537 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  67. 67

    Dziobek, I. et al. Neuronal correlates of altered empathy and social cognition in borderline personality disorder. Neuroimage 57, 539–548 (2011).

    PubMed  Article  Google Scholar 

  68. 68

    Bilek, E. et al. State-dependent cross-brain information flow in borderline personality disorder. JAMA Psychiatry 74, 949–957 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  69. 69

    O’Neill, A. et al. Dysregulation between emotion and theory of mind networks in borderline personality disorder. Psychiatry Res. 231, 25–32 (2015).

    PubMed  Article  Google Scholar 

  70. 70

    Herpertz, S. C., Bertsch, K. & Jeung, H. Neurobiology of Criterion A: self and interpersonal personality functioning. Curr. Opin. Psychol. 21, 23–27 (2017). This review provides the first thorough and systematic evaluation of the neurobiology of personality disorders within the framework of the DSM-5 AMPD, following the innovative approach of functional impairments instead of symptoms in personality disorders.

    PubMed  Article  PubMed Central  Google Scholar 

  71. 71

    Eisenberger, N. I. & Lieberman, M. D. Why rejection hurts: a common neural alarm system for physical and social pain. Trends Cogn. Sci. 8, 294–300 (2004).

    PubMed  Article  PubMed Central  Google Scholar 

  72. 72

    Domsalla, M. et al. Cerebral processing of social rejection in patients with borderline personality disorder. Soc. Cogn. Affect. Neurosci. 9, 1789–1797 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  73. 73

    Carpenter, R. W. & Trull, T. J. Components of emotion dysregulation in borderline personality disorder: a review. Curr. Psychiatry Rep. 15, 335 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  74. 74

    Bertsch, K. et al. Oxytocin and reduction of social threat hypersensitivity in women with borderline personality disorder. Am. J. Psychiatry 170, 1169–1177 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  75. 75

    Izurieta Hidalgo, N. A. et al. Time course of facial emotion processing in women with borderline personality disorder: an ERP study. J. Psychiatry Neurosci. 41, 16–26 (2016).

    PubMed  PubMed Central  Article  Google Scholar 

  76. 76

    Schneider, I. et al. Remnants and changes in facial emotion processing in women with remitted borderline personality disorder: an EEG study. Eur. Arch. Psychiatry Clin. Neurosci. https://doi.org/10.1007/s00406-017-0841-7 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  77. 77

    Schulze, L., Schmahl, C. & Niedtfeld, I. Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. Biol. Psychiatry 79, 97–106 (2016). This meta-analysis provides a large body of evidence that a dysfunctional amygdala and dorsolateral PFC are characteristic features of individuals with BPD.

    PubMed  Article  PubMed Central  Google Scholar 

  78. 78

    Kamphausen, S. et al. Medial prefrontal dysfunction and prolonged amygdala response during instructed fear processing in borderline personality disorder. World J. Biol. Psychiatry 14, 307–318 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  79. 79

    Hazlett, E. A. et al. Potentiated amygdala response to repeated emotional pictures in borderline personality disorder. Biol. Psychiatry 72, 448–456 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  80. 80

    Koenigsberg, H. W. et al. The neural correlates of anomalous habituation to negative emotional pictures in borderline and avoidant personality disorder patients. Am. J. Psychiatry 171, 82–90 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  81. 81

    Dyck, M. et al. Cognitive versus automatic mechanisms of mood induction differentially activate left and right amygdala. Neuroimage 54, 2503–2513 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  82. 82

    Hoerst, M. et al. Metabolic alterations in the amygdala in borderline personality disorder: a proton magnetic resonance spectroscopy study. Biol. Psychiatry 67, 399–405 (2010).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  83. 83

    Schienle, A., Leutgeb, V. & Wabnegger, A. Symptom severity and disgust-related traits in borderline personality disorder: the role of amygdala subdivisions. Psychiatry Res. 232, 203–207 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  84. 84

    Kuhlmann, A., Bertsch, K., Schmidinger, I., Thomann, P. A. & Herpertz, S. C. Morphometric differences in central stress-regulating structures between women with and without borderline personality disorder. J. Psychiatry Neurosci. 38, 129–137 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  85. 85

    Kreisel, S. H. et al. Volume of hippocampal substructures in borderline personality disorder. Psychiatry Res. 231, 218–226 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  86. 86

    Niedtfeld, I. et al. Voxel-based morphometry in women with borderline personality disorder with and without comorbid posttraumatic stress disorder. PLoS ONE 8, e65824 (2013).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  87. 87

    Kimmel, C. L. et al. Age-related parieto-occipital and other gray matter changes in borderline personality disorder: a meta-analysis of cortical and subcortical structures. Psychiatry Res. 251, 15–25 (2016).

    Article  Google Scholar 

  88. 88

    Mancke, F. et al. Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder. J. Psychiatry Neurosci. 43, 170132 (2017).

    PubMed  Google Scholar 

  89. 89

    Silvers, J. A. et al. Affective lability and difficulties with regulation are differentially associated with amygdala and prefrontal response in women with Borderline Personality Disorder. Psychiatry Res. 254, 74–82 (2016).

    PubMed Central  Article  Google Scholar 

  90. 90

    Koenigsberg, H. W. et al. Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with borderline personality disorder. Biol. Psychiatry 66, 854–863 (2009).

    PubMed  PubMed Central  Article  Google Scholar 

  91. 91

    Schulze, L. et al. Neuronal correlates of cognitive reappraisal in borderline patients with affective instability. Biol. Psychiatry 69, 564–573 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  92. 92

    Cullen, K. R. et al. Brain activation in response to overt and covert fear and happy faces in women with borderline personality disorder. Brain Imag. Behav. 10, 319–331 (2016).

    Article  Google Scholar 

  93. 93

    Herpertz, S. C. et al. Brain mechanisms underlying reactive aggression in borderline personality disorder-sex matters. Biol. Psychiatry 82, 257–266 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  94. 94

    Sato, J. R. et al. Can neuroimaging be used as a support to diagnosis of borderline personality disorder? An approach based on computational neuroanatomy and machine learning. J. Psychiatr. Res. 46, 1126–1132 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  95. 95

    Carrasco, J. L. et al. Microstructural white matter damage at orbitofrontal areas in borderline personality disorder. J. Affect. Disord. 139, 149–153 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  96. 96

    Schmitt, R., Winter, D., Niedtfeld, I., Herpertz, S. C. & Schmahl, C. Effects of psychotherapy on neuronal correlates of reappraisal in female patients with borderline personality disorder. Biol. Psychiatry Cogn. Neurosci. Neuroimag. 1, 548–557 (2016).

    Google Scholar 

  97. 97

    Scherpiet, S. et al. Reduced neural differentiation between self-referential cognitive and emotional processes in women with borderline personality disorder. Psychiatry Res. 233, 314–323 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  98. 98

    Müller, L. E. et al. Cortical representation of afferent bodily signals in borderline personality disorder: neural correlates and relationship to emotional dysregulation. JAMA Psychiatry 72, 1077–1086 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  99. 99

    Gentili, C. et al. Not in one metric: Neuroticism modulates different resting state metrics within distinctive brain regions. Behav. Brain Res. 327, 34–43 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  100. 100

    Turner, D., Sebastian, A. & Tüscher, O. Impulsivity and cluster B personality disorders. Curr. Psychiatry Rep. 19, 15 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  101. 101

    McHugh, C. & Balaratnasingam, S. Impulsivity in personality disorders: current views and future directions. Curr. Opin. Psychiatry 31, 63–68 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  102. 102

    Herbort, M. C. et al. A negative relationship between ventral striatal loss anticipation response and impulsivity in borderline personality disorder. NeuroImage Clin. 12, 724–736 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  103. 103

    Soloff, P. H., White, R., Omari, A., Ramaseshan, K. & Diwadkar, V. A. Affective context interferes with brain responses during cognitive processing in borderline personality disorder: fMRI evidence. Psychiatry Res. 233, 23–35 (2015).

    PubMed  PubMed Central  Article  Google Scholar 

  104. 104

    Silbersweig, D. et al. Failure of frontolimbic inhibitory function in the context of negative emotion in borderline personality disorder. Am. J. Psychiatry 164, 1832–1841 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  105. 105

    Jacob, G. A. et al. Emotional modulation of motor response inhibition in women with borderline personality disorder: an fMRI study. J. Psychiatry Neurosci. 38, 164–172 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  106. 106

    Schmahl, C. & Baumgärtner, U. Pain in borderline personality disorder. Mod. Trends Pharmacopsychiatry 30, 166–175 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  107. 107

    Reitz, S. et al. Incision and stress regulation in borderline personality disorder: neurobiological mechanisms of self-injurious behaviour. Br. J. Psychiatry 207, 165–172 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  108. 108

    Niedtfeld, I. et al. Functional connectivity of pain-mediated affect regulation in Borderline Personality Disorder. PLoS ONE 7, e33293 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  109. 109

    Willis, F. et al. The role of nociceptive input and tissue injury on stress regulation in borderline personality disorder. Pain 158, 479–487 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  110. 110

    Niedtfeld, I. et al. Pain-mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: a longitudinal fMRI study. Soc. Cogn. Affect. Neurosci. 12, 739–747 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  111. 111

    Glenn, J. J., Michel, B. D., Franklin, J. C., Hooley, J. M. & Nock, M. K. Pain analgesia among adolescent self-injurers. Psychiatry Res. 220, 921–926 (2014).

    PubMed  Article  Google Scholar 

  112. 112

    Carvalho Fernando, S. et al. Associations of childhood trauma with hypothalamic-pituitary-adrenal function in borderline personality disorder and major depression. Psychoneuroendocrinology 37, 1659–1668 (2012).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  113. 113

    Rausch, J. et al. Increased testosterone levels and cortisol awakening responses in patients with borderline personality disorder: gender and trait aggressiveness matter. Psychoneuroendocrinology 55, 116–127 (2015).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  114. 114

    Wingenfeld, K. & Wolf, O. T. Effects of cortisol on cognition in major depressive disorder, posttraumatic stress disorder and borderline personality disorder — 2014 Curt Richter Award Winner. Psychoneuroendocrinology 51, 282–295 (2015).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  115. 115

    Lyons-Ruth, K., Choi-Kain, L., Pechtel, P., Bertha, E. & Gunderson, J. Perceived parental protection and cortisol responses among young females with borderline personality disorder and controls. Psychiatry Res. 189, 426–432 (2011).

    CAS  PubMed  Article  Google Scholar 

  116. 116

    Bertsch, K., Schmidinger, I., Neumann, I. D. & Herpertz, S. C. Reduced plasma oxytocin levels in female patients with borderline personality disorder. Horm. Behav. 63, 424–429 (2013).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  117. 117

    Jobst, A. et al. Lower oxytocin plasma levels in borderline patients with unresolved attachment representations. Front. Hum. Neurosci. 10, 125 (2016).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  118. 118

    Smith, A. S. & Wang, Z. Hypothalamic oxytocin mediates social buffering of the stress response. Biol. Psychiatry 76, 281–288 (2014).

    CAS  PubMed  Article  Google Scholar 

  119. 119

    Simeon, D. et al. Oxytocin administration attenuates stress reactivity in borderline personality disorder: a pilot study. Psychoneuroendocrinology 36, 1418–1421 (2011).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  120. 120

    Lischke, A., Herpertz, S. C., Berger, C., Domes, G. & Gamer, M. Divergent effects of oxytocin on (para-)limbic reactivity to emotional and neutral scenes in females with and without borderline personality disorder. Soc. Cogn. Affect. Neurosci. 12, 1783–1792 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  121. 121

    Cataldo, I., Azhari, A., Lepri, B. & Esposito, G. Oxytocin receptors (OXTR) and early parental care: an interaction that modulates psychiatric disorders. Res. Dev. Disabil.https://doi.org/10.1016/j.ridd.2017.10.007 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

  122. 122

    Hammen, C., Bower, J. E. & Cole, S. W. Oxytocin receptor gene variation and differential susceptibility to family environment in predicting youth borderline symptoms. J. Pers. Disord. 29, 177–192 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  123. 123

    Cicchetti, D., Rogosch, F. A., Hecht, K. F., Crick, N. R. & Hetzel, S. Moderation of maltreatment effects on childhood borderline personality symptoms by gender and oxytocin receptor and FK506 binding protein 5 genes. Dev. Psychopathol. 26, 831–849 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  124. 124

    Dettenborn, L. et al. Increased hair testosterone but unaltered hair cortisol in female patients with borderline personality disorder. Psychoneuroendocrinology 71, 176–179 (2016).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  125. 125

    Volman, I., Toni, I., Verhagen, L. & Roelofs, K. Endogenous testosterone modulates prefrontal-amygdala connectivity during social emotional behavior. Cereb. Cortex 21, 2282–2290 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  126. 126

    Eisenlohr-Moul, T. A., DeWall, C. N., Girdler, S. S. & Segerstrom, S. C. Ovarian hormones and borderline personality disorder features: preliminary evidence for interactive effects of estradiol and progesterone. Biol. Psychol. 109, 37–52 (2015).

    PubMed  PubMed Central  Article  Google Scholar 

  127. 127

    Association, A. P. Diagnostic and Statistical Manual of Mental Disorders 5th edn (American Psychiatric Association, 2013).

    Google Scholar 

  128. 128

    Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K. & Martinez, J. Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity? J. Pers. Disord. 27, 244–251 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  129. 129

    Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K. & Martinez, J. Does the presence of one feature of borderline personality disorder have clinical significance? J. Clin. Psychiatry 73, 8–12 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  130. 130

    Ellison, W. D., Rosenstein, L., Chelminski, I., Dalrymple, K. & Zimmerman, M. The clinical significance of single features of borderline personality disorder: anger, affective instability, impulsivity, and chronic emptiness in psychiatric outpatients. J. Pers. Disord. 30, 261–270 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  131. 131

    World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders (WHO, Geneva, 1992).

  132. 132

    Zimmerman, M. & Mattia, J. I. Differences between clinical and research practices in diagnosing borderline personality disorder. Am. J. Psychiatry 156, 1570–1574 (1999).

    CAS  PubMed  Article  Google Scholar 

  133. 133

    Morey, L. C. & Benson, K. T. An investigation of adherence to diagnostic criteria, revisited: clinical diagnosis of the DSM-IV/DSM-5 Section II Personality Disorders. J. Pers. Disord. 30, 130–144 (2016).

    PubMed  Article  Google Scholar 

  134. 134

    Zanarini, M. C. et al. The collaborative longitudinal personality disorders study: reliability of Axis I and II diagnoses. J. Pers. Disord. 14, 291–299 (2000).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  135. 135

    Samuel, D. B. et al. Convergent and incremental predictive validity of clinician, self-report, and structured interview diagnoses for personality disorders over 5 years. J. Consult. Clin. Psychol. 81, 650–659 (2013).

    PubMed  PubMed Central  Article  Google Scholar 

  136. 136

    Hopwood, C. J. et al. A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria. Psychol. Assess. 20, 81–85 (2008).

    PubMed  Article  Google Scholar 

  137. 137

    Zimmerman, M., Multach, M. D., Dalrymple, K. & Chelminski, I. Clinically useful screen for borderline personality disorder in psychiatric out-patients. Br. J. Psychiatry 210, 165–166 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  138. 138

    Eaton, N. R. et al. Borderline personality disorder co-morbidity: relationship to the internalizing–externalizing structure of common mental disorders. Psychol. Med. 41, 1041–1050 (2010).

    PubMed  PubMed Central  Article  Google Scholar 

  139. 139

    Kotov, R. et al. The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J. Abnorm. Psychol. 126, 454–477 (2017). This article places BPD in a hierarchical structure spanning internalizing and externalizing spectra of psychopathology, helping to explain commonly observed comorbidities and suggesting the possibilities of shared risk factors, aetiology, pathophysiology, illness course and treatment response.

    PubMed  Article  PubMed Central  Google Scholar 

  140. 140

    McGlashan, T. H. et al. The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatr. Scand. 102, 256–264 (2000).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  141. 141

    Zanarini, M. C. et al. Axis I comorbidity of borderline personality disorder. Am. J. Psychiatry 155, 1733–1739 (1998).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  142. 142

    Zimmerman, M. & Mattia, J. I. Axis I diagnostic comorbidity and borderline personality disorder. Compr. Psychiatry 40, 245–252 (1999).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  143. 143

    Asherson, P. et al. Differential diagnosis, comorbidity, and treatment of attention-deficit/hyperactivity disorder in relation to bipolar disorder or borderline personality disorder in adults. Curr. Med. Res. Opin. 30, 1657–1672 (2014).

    CAS  PubMed  Article  Google Scholar 

  144. 144

    Feinstein, A. R. The pre-therapeutic classification of co-morbidity in chronic disease. J. Chron. Dis. 23, 455–468 (1970).

    CAS  PubMed  Article  Google Scholar 

  145. 145

    Gunderson, J. G. et al. Major depressive disorder and borderline personality disorder revisited. J. Clin. Psychiatry 65, 1049–1056 (2004).

    PubMed  Article  Google Scholar 

  146. 146

    Boritz, T., Barnhart, R. & McMain, S. F. The influence of posttraumatic stress disorder on treatment outcomes of patients with borderline personality disorder. J. Pers. Disord. 30, 395–407 (2016).

    PubMed  Article  Google Scholar 

  147. 147

    Keuroghlian, A. S. et al. Interactions of borderline personality disorder and anxiety disorders over 10 years. J. Clin. Psychiatry 76, 1529–1534 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  148. 148

    Skodol, A. E. et al. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. Am. J. Psychiatry 168, 257–264 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  149. 149

    Hasin, D. Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders. Arch. Gen. Psychiatry 68, 1158 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  150. 150

    Gunderson, J. G. et al. Interactions of borderline personality disorder and mood disorders over 10 years. J. Clin. Psychiatry 75, 829–834 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  151. 151

    Quirk, S. E. et al. Personality disorders and physical comorbidities in adults from the United States: data from the National Epidemiologic Survey on Alcohol and Related Conditions. Soc. Psychiatry Psychiatr. Epidemiol. 50, 807–820 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  152. 152

    Chanen, A. M. et al. The HYPE Clinic: an early intervention service for borderline personality disorder. J. Psychiatr. Pract. 15, 163–172 (2009).

    PubMed  Article  Google Scholar 

  153. 153

    Marieke Schuppert, H. et al. Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial. J. Am. Acad. Child Adolesc. Psychiatry 51, 1314–1323.e2 (2012).

    PubMed  Article  Google Scholar 

  154. 154

    Chanen, A. M. et al. Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial. Br. J. Psychiatry 193, 477–484 (2008).

    PubMed  Article  Google Scholar 

  155. 155

    Zanarini, M. C. & Frankenburg, F. R. A. Preliminary, randomized trial of psychoeducation for women with borderline personality disorder. J. Pers. Disord. 22, 284–290 (2008).

    PubMed  Article  Google Scholar 

  156. 156

    Zimmerman, M., Ruggero, C. J., Chelminski, I. & Young, D. Psychiatric diagnoses in patients previously overdiagnozed with bipolar disorder. J. Clin. Psychiatry 71, 26–31 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  157. 157

    Paris, J. Why psychiatrists are reluctant to diagnose: borderline personality disorder. Psychiatry 4, 35–39 (2007).

    PubMed  Google Scholar 

  158. 158

    Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Harned, A. L. & Fitzmaurice, G. M. Rates of psychotropic medication use reported by borderline patients and Axis II comparison subjects over 16 years of prospective follow-up. J. Clin. Psychopharmacol. 35, 63–67 (2015).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  159. 159

    Kendall, T., Burbeck, R. & Bateman, A. Pharmacotherapy for borderline personality disorder: NICE guideline. Br. J. Psychiatry 196, 158–159 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  160. 160

    Gabbard, G. O. Do all roads lead to Rome? New Findings Borderline Personal. Disorder. Am. J. Psychiatry 164, 853–855 (2007).

    Google Scholar 

  161. 161

    Gunderson, J. G. Borderline personality disorder. N. Engl. J. Med. 364, 2037–2042 (2011).

    CAS  PubMed  Article  Google Scholar 

  162. 162

    Linehan, M. M. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch. Gen. Psychiatry 48, 1060 (1991). This article presents the first randomized control trial to demonstrate that BPD can be successfully treated. This report irrevocably changed this disorder's reputation for untreatability.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  163. 163

    Linehan, M. M. et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder. JAMA Psychiatry 72, 475 (2015).

    PubMed  Article  CAS  Google Scholar 

  164. 164

    Bateman, A. & Fonagy, P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am. J. Psychiatry 166, 1355–1364 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  165. 165

    McMain, S. F. et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am. J. Psychiatry 166, 1365–1374 (2009).

    PubMed  Article  PubMed Central  Google Scholar 

  166. 166

    Yeomans, F. E., Clarkin, J. F. & Kernberg, O. F. A Primer on Transference-Focused Psychotherapy for the Borderline Patient. (J. Aronson, 2002).

    Google Scholar 

  167. 167

    Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A. & Unruh, B. T. What works in the treatment of borderline personality disorder. Curr. Behav. Neurosci. Rep. 4, 21–30 (2017).

    PubMed  PubMed Central  Article  Google Scholar 

  168. 168

    Gunderson, J. G. The emergence of a generalist model to meet public health needs for patients with borderline personality disorder. Am. J. Psychiatry 173, 452–458 (2016). This article serves notice that less intensive, easier-to-learn models of treatment can be effective for most patients with BPD.

    PubMed  Article  PubMed Central  Google Scholar 

  169. 169

    Gunderson, J. G. & Links, P. S. Handbook of Good Psychiatric Management for Borderline Personality Disorder. (American Psychiatric Publishing, 2014).

    Google Scholar 

  170. 170

    Choi-Kain, L. W., Albert, E. B. & Gunderson, J. G. Evidence-based treatments for borderline personality disorder. Harv. Rev. Psychiatry 24, 342–356 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  171. 171

    Chanen, A. M. & McCutcheon, L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. Br. J. Psychiatry 202, s24–s29 (2013).

    Article  Google Scholar 

  172. 172

    Zanarini, M. C. et al. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harv. Rev. Psychiatry 6, 201–207 (1998).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  173. 173

    Lieb, K., Vollm, B., Rucker, G., Timmer, A. & Stoffers, J. M. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br. J. Psychiatry 196, 4–12 (2009).

    Article  Google Scholar 

  174. 174

    Pennay, A. et al. A systematic review of interventions for co-occurring substance use disorder and borderline personality disorder. J. Subst. Abuse Treat. 41, 363–373 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  175. 175

    Lee, N. K., Cameron, J. & Jenner, L. A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug Alcohol Rev. 34, 663–672 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  176. 176

    Bohus, M. et al. Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychother. Psychosom. 82, 221–233 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  177. 177

    Harned, M. S., Korslund, K. E. & Linehan, M. M. A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav. Res. Ther. 55, 7–17 (2014).

    PubMed  PubMed Central  Article  Google Scholar 

  178. 178

    Ingenhoven, T. Pharmacotherapy for borderline patients: business as usual or by default? J. Clin. Psychiatry 76, e522–e523 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  179. 179

    NICE. Borderline Personality Disorder: Treatment and Management. (British Psychological Society, Great Britain, 2009). This scholarly and critical review of psychoactive medication use concludes that BPD symptoms are not responsive and that medications should be prescribed sparingly.

  180. 180

    Crawford, M. J. et al. The clinical effectiveness and cost-effectiveness of lamotrigine in borderline personality disorder: a randomized placebo-controlled trial. Am. J. Psychiatryhttps://doi.org/10.1176/appi.ajp.2018.17091006 (2018).

    PubMed  Article  PubMed Central  Google Scholar 

  181. 181

    Hoffman, P. D. et al. Family Connections: a program for relatives of persons with borderline personality disorder. Fam. Process 44, 217–225 (2005).

    PubMed  Article  PubMed Central  Google Scholar 

  182. 182

    Gunderson, J. G., Berkowitz, C. & Ruiz-Sancho, A. Families of borderline patients: a psychoeducational approach. Bull. Menninger Clin. 61, 446–457 (1997).

    CAS  PubMed  PubMed Central  Google Scholar 

  183. 183

    Jørgensen, C. R. et al. Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial. Acta Psychiatr. Scand. 127, 305–317 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  184. 184

    Gunderson, J. Predictors of 2-year outcome for patients with borderline personality disorder. Am. J. Psychiatry 163, 822 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  185. 185

    Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B. & Silk, K. R. Prediction of the 10-year course of borderline personality disorder. Am. J. Psychiatry 163, 827–832 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  186. 186

    Zanarini, M. The subsyndromal phenomenology of borderline personality disorder: a 10-year follow-up study. Am. J. Psychiatry 164, 929 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  187. 187

    Zanarini, M. C., Frankenburg, F. R., Reich, D. B. & Fitzmaurice, G. M. Fluidity of the subsyndromal phenomenology of borderline personality disorder over 16 years of prospective follow-up. Am. J. Psychiatry 173, 688–694 (2016).

    PubMed  PubMed Central  Article  Google Scholar 

  188. 188

    McGlashan, T. H. et al. Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of Axis II disorders. Am. J. Psychiatry 162, 883–889 (2005).

    PubMed  PubMed Central  Article  Google Scholar 

  189. 189

    Lenzenweger, M. F., Lane, M. C., Loranger, A. W. & Kessler, R. C. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol. Psychiatry 62, 553–564 (2007).

    PubMed  PubMed Central  Article  Google Scholar 

  190. 190

    Skodol, A. E. et al. Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive–compulsive personality disorder over two years. Psychol. Med. 35, 443–451 (2005).

    PubMed  PubMed Central  Article  Google Scholar 

  191. 191

    Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B. & Silk, K. R. Psychosocial functioning of borderline patients and Axis II comparison subjects followed prospectively for six years. J. Pers. Disord. 19, 19–29 (2005).

    PubMed  Article  PubMed Central  Google Scholar 

  192. 192

    Zanarini, M. C., Frankenburg, F. R., Reich, D. B. & Fitzmaurice, G. The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatr. Scand. 122, 103–109 (2010). This paper demonstrates that unexpectedly high rates of both symptomatic and functional recovery are achievable over 16 years by patients with BPD.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  193. 193

    Zanarini, M. C., Frankenburg, F. R., Reich, D. B. & Fitzmaurice, G. Time to attainment of recovery from borderline personality disorder and stability of recovery: a 10-year prospective follow-up study. Am. J. Psychiatry 167, 663–667 (2010).

    PubMed  PubMed Central  Article  Google Scholar 

  194. 194

    Zanarini, M. C. et al. The course of marriage/sustained cohabitation and parenthood among borderline patients followed prospectively for 16 years. J. Pers. Disord. 29, 62–70 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  195. 195

    Frankenburg, F. R. & Zanarini, M. C. The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. J. Clin. Psychiatry 65, 1660–1665 (2004).

    PubMed  Article  PubMed Central  Google Scholar 

  196. 196

    Keuroghlian, A. S., Frankenburg, F. R. & Zanarini, M. C. The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. J. Psychiatr. Res. 47, 1499–1506 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  197. 197

    El-Gabalawy, R., Katz, L. Y. & Sareen, J. Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosom. Med. 72, 641–647 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  198. 198

    Kochanek, K. D., Murphy, S. L., Xu, J. & Tejada-Vera, B. Deaths: Final Data for 2014. Natl Vital Stat. Rep. 65, 1–122 (2016).

    PubMed  Google Scholar 

  199. 199

    Sharp, C. et al. The structure of personality pathology: both general (‘g’) and specific (‘s’) factors? J. Abnorm. Psychol. 124, 387–398 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  200. 200

    Wright, A. G. C., Hopwood, C. J., Skodol, A. E. & Morey, L. C. Longitudinal validation of general and specific structural features of personality pathology. J. Abnorm. Psychol. 125, 1120–1134 (2016). This study confirms that BPD represents general impairments shared across other personality disorders, which showed lower absolute stability but stronger relationships to concurrent and prospective psychosocial functioning than specific features that were more stable in a 10-year longitudinal study.

    PubMed  PubMed Central  Article  Google Scholar 

  201. 201

    Sanislow, C. A. et al. Developing constructs for psychopathology research: Research domain criteria. J. Abnorm. Psychol. 119, 631–639 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  202. 202

    American Psychiatric Association. DSM-III. Diagnostic and Statistical Manual of Mental Disorders 3rd edn (American Psychiatric Press, 1980).

  203. 203

    Saulsman, L. M. & Page, A. C. The five-factor model and personality disorder empirical literature: a meta-analytic review. Clin. Psychol. Rev. 23, 1055–1085 (2004).

    PubMed  Article  PubMed Central  Google Scholar 

  204. 204

    Samuel, D. B & Widiger, T. A. A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis. Clin. Psychol. Rev. 28, 1326–1342 (2008).

    PubMed  PubMed Central  Article  Google Scholar 

  205. 205

    Morey, L. C., Benson, K. T. & Skodol, A. E. Relating DSM-5 section III personality traits to section II personality disorder diagnoses. Psychol. Med. 46, 647–655 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  206. 206

    Herpertz, S. C. et al. The challenge of transforming the diagnostic system of personality disorders. J. Pers. Disord. 31, 577–589 (2017). This report summarizes the controversy about classifying personality disorders from within the dimensional trait-based perspective versus retaining the categorical model that has been in use, concluding that change should proceed incrementally.

    PubMed  PubMed Central  Article  Google Scholar 

  207. 207

    Winsper, C. et al. Clinical and psychosocial outcomes of borderline personality disorder in childhood and adolescence: a systematic review. Psychol. Med. 45, 2237–2251 (2015). This comprehensive review shows that borderline pathology prior to the age of 19 years is predictive of subsequent symptoms and deficits in functioning up to 20 years later, suggesting the clinical utility of the BPD phenotype in younger populations and warranting early intervention.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  208. 208

    Crawford, T. N. et al. Comorbid Axis I and Axis II disorders in early adolescence. Arch. Gen. Psychiatry 65, 641 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  209. 209

    Ha, C., Balderas, J. C., Zanarini, M. C., Oldham, J. & Sharp, C. Psychiatric comorbidity in hospitalized adolescents with borderline personality disorder. J. Clin. Psychiatry 75, e457–e464 (2014).

    PubMed  Article  PubMed Central  Google Scholar 

  210. 210

    Wright, A. G. C., Zalewski, M., Hallquist, M. N., Hipwell, A. E. & Stepp, S. D. Developmental trajectories of borderline personality disorder symptoms and psychosocial functioning in adolescence. J. Pers. Disord. 30, 351–372 (2016).

    PubMed  Article  PubMed Central  Google Scholar 

  211. 211

    Chanen, A. M. Borderline personality disorder in young people: are we there yet? J. Clin. Psychol. 71, 778–791 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  212. 212

    Sharp, C. & Fonagy, P. Practitioner Review: Borderline personality disorder in adolescence — recent conceptualization, intervention, and implications for clinical practice. J. Child Psychol. Psychiatry 56, 1266–1288 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  213. 213

    Morey, L. C. et al. State effects of major depression on the assessment of personality and personality disorder. Am. J. Psychiatry 167, 528–535 (2010).

    PubMed  PubMed Central  Article  Google Scholar 

  214. 214

    Zimmerman, M. & Morgan, T. A. Problematic boundaries in the diagnosis of bipolar disorder: the interface with borderline personality disorder. Curr. Psychiatry Rep. 15, 422 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  215. 215

    Ruggero, C. J., Zimmerman, M., Chelminski, I. & Young, D. Borderline personality disorder and the misdiagnosis of bipolar disorder. J. Psychiatr. Res. 44, 405–408 (2010).

    PubMed  Article  PubMed Central  Google Scholar 

  216. 216

    Zimmerman, M. et al. Distinguishing bipolar II depression from major depressive disorder with comorbid borderline personality disorder. J. Clin. Psychiatry 74, 880–886 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  217. 217

    Soeteman, D. I., Hakkaart-van Roijen, L., Verheul, R. & Busschbach, J. J. V. The economic burden of personality disorders in mental health care. J. Clin. Psychiatry 69, 259–265 (2008).

    PubMed  Article  PubMed Central  Google Scholar 

  218. 218

    Meuldijk, D., McCarthy, A., Bourke, M. E. & Grenyer, B. F. S. The value of psychological treatment for borderline personality disorder: systematic review and cost offset analysis of economic evaluations. PLoS ONE 12, e0171592 (2017). This thoughtful analysis of the direct costs of BPD and how evidence-based care can more than offset this establishes a basis for good reimbursement standard.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  219. 219

    van Asselt, A. D. I., Dirksen, C. D., Arntz, A. & Severens, J. L. The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur. Psychiatry 22, 354–361 (2007).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  220. 220

    Bailey, R. C., G. B. Burden and support needs of carers of persons with borderline personality disorder: a systematic review. Harv. Rev. Psychiatry 21, 248–258 (2013).

    PubMed  PubMed Central  Google Scholar 

  221. 221

    Page, A., Hooke, G., O’Brien, N. & de Felice, N. Assessment of distress and burden in Australian private psychiatric inpatients. Australas. Psychiatry 14, 285–290 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  222. 222

    Ekdahl, S., Idvall, E., Samuelsson, M. & Perseius, K.-I. A. Life tiptoeing: being a significant other to persons with borderline personality disorder. Arch. Psychiatr. Nurs. 25, e69–e76 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  223. 223

    Goodman, M. et al. Parental burden associated with borderline personality disorder in female offspring. J. Pers. Disord. 25, 59–74 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  224. 224

    Stern, A. Psychoanalytic investigation of and therapy in the borderline group of neuroses. Psychoanal Q. 7, 467–489 (1938).

    Article  Google Scholar 

  225. 225

    Knight, R. P. Borderline states. Bull. Menninger Clin. 17, 1–12 (1953).

    CAS  PubMed  PubMed Central  Google Scholar 

  226. 226

    Kernberg, O. Borderline personality organization. J. Am. Psychoanal. Assoc. 15, 641–685 (1967). This psychoanalytic conception of borderline patients ignited hopes that these patients could be distinguishable and that they were treatable.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  227. 227

    Kety, S. S., Rosenthal, D., Wender, P. H. & Schulsinger, F. The types and prevalence of mental illness in the biological and adoptive families of adopted schizophrenics. J. Psychiatr. Res. 6, 345–362 (1968).

    Article  Google Scholar 

  228. 228

    Grinker, R. R., Werble, B. & Drye, R. C. Borderline Syndrome: A Behavioral Study of Ego-Functions. (Basic Books, 1968).

    Google Scholar 

  229. 229

    Gunderson, J. G. & Kolb, J. E. Discriminating features of borderline patients. Am. J. Psychiatry 135, 792–796 (1978). This article identifies a reliably assessed and discriminating set of criteria that became the official definition of BPD in the DSM-III.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  230. 230

    Spitzer, R. L., Endicott, J. & Gibbon, M. Crossing the border into borderline personality and borderline schizophrenia. The development of criteria. Arch. Gen. Psychiatry 36, 17–24 (1979).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  231. 231

    Haas, B. W. & Miller, J. D. Borderline personality traits and brain activity during emotional perspective taking. Personal. Disord. 6, 315–320 (2015).

    PubMed  Article  Google Scholar 

  232. 232

    First, M. et al. Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II) (American Psychiatric Press, Inc., 1997).

    Google Scholar 

  233. 233

    Zanarini, M. C., Frankenburg, F. R., Chauncey, D. L. & Gunderson, J. G. The diagnostic interview for personality disorders: Interrater and test-retest reliability. Compr. Psychiatry 28, 467–480 (1987).

    CAS  PubMed  Article  Google Scholar 

  234. 234

    Loranger, A. W. International Personality Disorder Examination Manual (1999).

  235. 235

    Pfohl, B., Blum, N. S. & Zimmerman, M. Structured interview for DSM-IV personality: SIDP-IV. (American Psychiatric Press, 1997).

    Google Scholar 

  236. 236

    First, M. B., Skodol, A. E., Bender, D. S. & Oldham, J. M. User's Guide for the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD) (American Psychiatric Association, 2018).

    Google Scholar 

  237. 237

    Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R. & Chauncey, D. L. The revised diagnostic interview for borderlines: discriminating BPD from other Axis II disorders. J. Pers. Disord. 3, 10–18 (1989).

    Article  Google Scholar 

  238. 238

    Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R.,& Chauncey, D. L. Discriminating borderline personality disorder from other Axis II disorders. Am. J. Psychiatry 147, 161–167 (1990).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  239. 239

    Sharp, C., Ha, C., Michonski, J., Venta, A. & Carbone, C. Borderline personality disorder in adolescents: evidence in support of the Childhood Interview for DSM-IV Borderline Personality Disorder in a sample of adolescent inpatients. Compr. Psychiatry 53, 765–774 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  240. 240

    Arntz, A. et al. Reliability and validity of the Borderline Personality Disorder Severity Index. J. Pers. Disord. 17, 45–59 (2003).

    PubMed  Article  PubMed Central  Google Scholar 

  241. 241

    Zanarini, M. C. Zanarini Rating Scale For Borderline Personality Disorder (ZAN-BPD): a continuous measure of DSM-IV borderline psychopathology. J. Pers. Disord. 17, 233–242 (2003).

    PubMed  Article  PubMed Central  Google Scholar 

  242. 242

    Zanarini, M. C., Weingeroff, J. L., Frankenburg, F. R. & Fitzmaurice, G. M. Development of the self-report version of the Zanarini Rating Scale for Borderline Personality Disorder. Personal. Ment. Health 9, 243–249 (2015).

    PubMed  PubMed Central  Article  Google Scholar 

  243. 243

    Grant, B. F. et al. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): reliability of substance use and psychiatric disorder modules in a general population sample. Drug Alcohol Depend. 148, 27–33 (2015).

    PubMed  Article  PubMed Central  Google Scholar 

  244. 244

    Hyler, S. E. Personality Diagnostic Questionnaire-4. (New York State Psychiatric Institute, 1994).

    Google Scholar 

  245. 245

    Morey, L. C. Personality Assessment Inventory Professional Manual. (Psychological Assessment Resources, 1991).

    Google Scholar 

  246. 246

    Bohus, M. et al. Psychometric properties of the Borderline Symptom List (BSL). Psychopathology 40, 126–132 (2007).

    PubMed  Article  PubMed Central  Google Scholar 

  247. 247

    Mullins-Sweatt, S. N. et al. Five-factor measure of borderline personality traits. J. Pers. Assess. 94, 475–487 (2012).

    PubMed  Article  PubMed Central  Google Scholar 

  248. 248

    Clark, L. A., Simms, L. J., Wu, K. D. & Casillas, A. Manual for the Schedule for Nonadaptive and Adaptive Personality (SNAP-2). (Univ. of Minnesota Press, 2008).

    Google Scholar 

  249. 249

    John Livesley, W. & Douglas Jackson, N. Dimensional Assessment of Personality Pathology. SIGMA Assessment Systemshttp://www.sigmaassessmentsystems.com/assessments/dimensional-assessment-of-personality-pathology-basic-questionnaire/ (2009).

  250. 250

    Sellbom, M. & Smith, A. Assessment of DSM-5 section II personality disorders with the MMPI-2-RF in a nonclinical sample. J. Pers. Assess. 99, 384–397 (2016).

    PubMed  Article  Google Scholar 

  251. 251

    Krueger, R. F., Derringer, J., Markon, K. E., Watson, D. & Skodol, A. E. Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol. Med. 42, 1879–1890 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  252. 252

    Zanarini, M. C. et al. A screening measure for BPD: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). J. Pers. Disord. 17, 568–573 (2003).

    PubMed  Article  PubMed Central  Google Scholar 

  253. 253

    Chang, B., Sharp, C. & Ha, C. The criterion validity of the borderline personality features scale for children in an adolescent inpatient setting. J. Pers. Disord. 25, 492–503 (2011).

    PubMed  Article  PubMed Central  Google Scholar 

  254. 254

    Poreh, A. M. et al. The BPQ: a scale for the assessment of borderline personality based on DSM-IV criteria. J. Pers. Disord. 20, 247–260 (2006).

    PubMed  Article  PubMed Central  Google Scholar 

  255. 255

    Verheul, R. et al. Severity Indices of Personality Problems (SIPP-118): development, factor structure, reliability, and validity. Psychol. Assess. 20, 23–34 (2008).

    PubMed  Article  Google Scholar 

  256. 256

    Hentschel, A. G. & Livesley, W. J. The General Assessment of Personality Disorder (GAPD): factor structure, incremental validity of self-pathology, and relations to DSM–IV personality disorders. J. Pers. Assess. 95, 479–485 (2013).

    PubMed  Article  PubMed Central  Google Scholar 

  257. 257

    Morey, L. C. Development and initial evaluation of a self-report form of the DSM-5 Level of Personality Functioning Scale. Psychol. Assess. 29, 1302–1308 (2017).

    PubMed  Article  PubMed Central  Google Scholar 

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Contributions

Introduction (J.G.G.); Epidemiology (S.T.); Mechanisms/pathophysiology (S.C.H.); Diagnosis, screening and prevention (A.E.S.); Management (J.G.G.); Quality of life (M.C.Z.); Outlook (J.G.G.); Overview of Primer (J.G.G.).

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Correspondence to John G. Gunderson.

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Competing interests

S.C.H. was the past president of the International Society for the Study of Personality Disorders. A.E.S. receives author and editor royalties from American Psychiatric Association Publishing and from UpToDate. All other authors declare no competing interests.

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Gunderson, J., Herpertz, S., Skodol, A. et al. Borderline personality disorder. Nat Rev Dis Primers 4, 18029 (2018). https://doi.org/10.1038/nrdp.2018.29

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